LIFE IN THE END ZONE: A discussion of topical issues for anyone concerned with the final phase of life by Muriel R. Gillick, MD

April 20, 2015

Helping the Other Half

There’s nothing much new in
the latest edition of the Alzheimer’s Association Alzheimer’s Facts and Figures, which came out last month. Once again, the report documents that about 43% of
people age 75-84 have Alzheimer’s. Since no more than 75% of all dementia cases
are due to Alzheimer’s disease, that means that over half of people in this age group have dementia of one
kind or another.

The proportion varies
depending on how dementia was assessed and on the ethnic, geographic, and
gender composition of the people studied. But despite an enormous amount of
effort and much progress in the domain of understanding the pathophysiology of
Alzheimer’s disease, the Alzheimer’s Association reminds us that there is no
drug available today that slows or stops the death or neurons that causes
Alzheimer’s disease.

The federal government’s
National Alzheimer’s Project Act and Obama’s BRAIN (Brain Research Through
Advancing Innovative Neurotechnologies) initiative are redoubling the effort to
find a cure. That would be terrific—though we should remember that the last
concerted effort to wipe out a chronic disease, the War on Cancer, was launched
in 1971 and is still being fought.

But what about the other
half—those older people who don’t have dementia? Is there anything that
medicine should be doing special for them?

A new report from the
well-respected, non-governmental, non-profit Institute of Medicine released
last week addresses this question. Entitled Cognitive Aging: Progress in Understanding and Opportunities for Action, the report makes ten
recommendations for collecting data, engaging in research, developing programs,
and providing resources that seek to maximize cognitive function in older
people who don’t have dementia. It’s an intriguing report, principally because
it focuses on what is most important to older people and is the essence of
geriatric medicine—function, rather than disease. The authors cite an AARP
survey of members in which fully 87% identified “remaining sharp” as one of their
major concerns. Older individuals and their families are concerned with
optimizing mental performance. They are alarmed by the recently described
disorder, “Mild Cognitive Impairment,” a condition that does not meet the
criteria for dementia but affects the ability to function in day to day life,
whether or not it progresses to full-blown dementia.

The study is also of interest
because of it public health angle—it draws attention to the major societal
consequences of age-related cognitive decline, things like traffic accidents
(as people with impaired judgment or slow reflexes continue to drive) and
financial fraud (resulting from impaired decision-making on the one hand and
minimal consumer protections on the other). The recommendation to develop
assessment tools, educational programs, and improved regulations, as well as
alternative means of transportation, have the potential to maintain quality of
life for older individuals and to lower costs.

The report makes common-sense
suggestions for preventing age-related cognitive decline: being physically
active, remaining socially and intellectually engaged and getting enough sleep.
Unfortunately, there is no more evidence that these measures will maintain
cognitive function than there is that they will prevent dementia. That is, they
might help and they can’t hurt. But to suggest that they are proven to be
effective is, alas, to overstate the case.

Despite succumbing to the
temptation to offer a little bit of hype along with a lot of wisdom, the report’s authors make a
valuable contribution by reminding us to pay attention to the other half. Its
broad societal focus is welcome, as is the recognition that it is function
rather than disease that matters most to the majority of people as they age.